Pillars Of North County Health & Rehab Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 13700 Old Halls Ferry Road, Florissant, Missouri 63033
- CMS Provider Number
- 265341
- Inspections on file
- 19
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pillars Of North County Health & Rehab Center, The during CMS and state inspections, most recent first.
Staff did not immediately report a resident's sexual abuse allegation against a CNA to administration, as required by facility policy. Instead, the incident was only disclosed to the DON and the resident's family after police were called for an unrelated wellness check. The resident, who had dementia and other conditions, later denied the allegation, but the delay in reporting constituted a deficiency in abuse prevention procedures.
A resident with a history of stroke, malnutrition, and a g-tube did not receive prescribed tube feedings and water flushes as ordered, and staff failed to follow standard practices for enteral nutrition management, including verifying tube placement, checking residuals, and accurately monitoring intake and weight. The feeding pump frequently malfunctioned, and incomplete feedings were not documented or reported to the physician. Facility leadership and the Medical Director were unaware of these issues, and family concerns about weight loss and inadequate care were not fully investigated.
Four residents with conditions requiring pureed diets, including those with dysphagia and neurological impairments, were served pureed chicken that was not prepared to the correct texture because dietary staff failed to follow the recipe and omitted the required thickener, resulting in an improper meal consistency.
Surveyors found that the facility did not keep the walk-in refrigerator at or below 41°F as required, with temperature logs missing for two days and thermometer readings above the standard. Additionally, three residents had water containers with visible brown substances, and staff confirmed that daily cleaning and proper supply of water pitchers were not consistently maintained.
Surveyors identified multiple deficiencies in environmental cleanliness and safety, including unclean bathroom vents with dust and cobwebs, plungers stored directly on the floor, urinals improperly stored on handrails, a missing bathroom light cover, and a broken bed footboard with exposed nails and screws. The Maintenance Director confirmed these issues during follow-up observations and stated that maintenance requests had not been received for these problems.
Two residents with significant medical conditions and fall risks were repeatedly observed with their call lights out of reach, despite staff acknowledging responsibility for ensuring accessibility. One resident's call light was clipped to a privacy curtain, while another's was draped over a wall fixture, leaving both unable to summon assistance as needed.
A resident with quadriplegia and intact cognition was not provided with his preferred shower and instead received bed baths, despite staff being aware of his preference. The care plan did not address his bathing choice, and staff cited a broken shower bed and an unsuitable shower chair as reasons for not accommodating his request.
A resident with multiple diagnoses and intact cognition reported being verbally abused by a CNA, but the allegation was not promptly reported or investigated according to facility policy. The Activity Director received the report but did not initiate an investigation or notify the Administrator, resulting in a delay in reporting the incident to the appropriate authorities.
A resident was admitted with psychiatric diagnoses including schizoaffective disorder, anxiety disorder, and major depressive disorder, but the facility did not complete a required Level Two PASARR assessment. The resident exhibited moderate cognitive impairment and behavioral issues, and staff interviews confirmed that the necessary assessment was not performed due to lack of notification and awareness.
Two residents did not have comprehensive care plans addressing their specific needs: one resident with pain and multiple pain medications lacked a care plan for pain management, while another resident with severe cognitive impairment and total dependence on staff for ADLs had no care plan for ADL assistance. These omissions were confirmed by the MDS Coordinator.
A resident who was fully dependent on staff for care and had moderate cognitive impairment was observed with excessively long fingernails on multiple occasions, despite a care plan requiring grooming. The resident stated a preference for trimmed nails, but staff interviews revealed confusion about responsibility for nail care, especially for hospice patients, resulting in the resident's needs not being met.
A resident with quadriplegia and other medical conditions was not properly notified of a scheduled physician appointment, resulting in the resident being unable to prepare in time and subsequently missing the appointment. Documentation of the appointment existed, but unclear staff responsibilities and communication breakdowns led to the deficiency.
A resident with ESRD missed a dialysis appointment due to transportation issues, and staff failed to administer the ordered as-needed Lokelma, document the missed appointment, or notify the physician. The LPN on duty was unaware of the as-needed order, and the DON was not informed of the incident.
A resident with a mouth infection and dental issues did not receive a dentist visit as ordered by the physician. Although antibiotics and pain relief were prescribed, there was no record of a dental appointment being scheduled or completed. Staff interviews revealed that the order for a dental visit was not communicated to the Social Services Director or receptionist, and the DON confirmed the resident was not seen by a dentist due to this lapse.
The facility did not ensure physician orders in the EMR were accurate and current for three residents, resulting in outdated orders for hospice, dialysis, and restorative services. In each case, orders remained active despite changes in the residents' care needs or service locations, and staff confirmed the inaccuracies and lack of timely updates.
Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for three residents on Enhanced Barrier Precautions, including wound care and incontinence care. Observations showed that a wound physician, a wound LPN, and two CNAs provided care without donning gowns, despite facility policy and posted signage requiring this protection for residents with open wounds or other qualifying conditions.
Two residents who had consented to receive influenza or pneumococcal vaccines were not administered the vaccines as required. Documentation in the EMR confirmed the lack of administration, and the Infection Preventionist acknowledged that these vaccinations were missed despite proper consent.
The facility failed to follow its pressure ulcer and wound care policies, resulting in deficiencies for two residents. One resident's wound care orders and dietician recommendations were not promptly implemented, and pressure ulcers on the feet were not identified or reported. Another resident was admitted with a pressure ulcer but lacked a treatment order for several days, and dietician recommendations were delayed. The facility's lack of communication and documentation led to inadequate care.
The facility failed to monitor a resident diagnosed with COVID-19 according to their policy. Despite changes in the resident's condition being reported, vital signs and assessments were not documented. The resident was found unresponsive and later pronounced dead, with the cause of death determined to be COVID-19. The Director of Nursing confirmed that the facility's policies were not followed.
Failure to Immediately Report Abuse Allegation to Administration
Penalty
Summary
Facility staff failed to follow the established Abuse Prevention Program policy, which requires immediate reporting of any incident, allegation, or suspicion of abuse to the administrator. In this case, a resident with diagnoses including dementia, heart failure, mood disturbance, anxiety, and psychotic disturbance accused a CNA of sexual assault while being assisted to bed. The CNA immediately informed two other CNAs of the allegation, but none of the staff reported the incident to administration as required. Instead, they dismissed the allegation, believing it to be untrue, and considered the matter resolved among themselves. The deficiency was discovered when the resident's family member, unaware of the abuse allegation, called the police for a wellness check due to concerns about the resident being soiled and not changed by staff. Upon the police's arrival, a CNA informed the family member about the previous day's abuse allegation, which was the first time the family and administrative staff became aware of the incident. The DON was then notified and initiated an investigation. The resident later denied the abuse allegation and stated a preference against care from staff of the opposite sex. The failure to report the allegation immediately to administration constituted noncompliance with the facility's abuse reporting policy.
Failure to Follow Physician Orders and Provide Adequate G-Tube Management
Penalty
Summary
The facility failed to provide services that meet professional standards by not following physician orders and not ensuring adequate management of a resident's enteral gastrostomy tube (g-tube). The resident, who had a history of cerebral infarction, hemiplegia, aphasia, myocardial infarction, severe protein-calorie malnutrition, and was admitted with a g-tube, was supposed to receive continuous tube feeding and regular g-tube flushes as ordered by the physician. However, documentation showed that the prescribed tube feedings and water flushes were not consistently administered, and there were no orders or documentation for essential aspects of g-tube care such as residual checks, placement verification, or monitoring intake and output. The facility also lacked clear policies and procedures for these standard practices. Observations and interviews revealed that the resident's feeding pump frequently malfunctioned, resulting in incomplete delivery of nutrition, and staff did not consistently document the amount of feeding received or notify the physician when feedings were missed or incomplete. The resident was observed lying flat in bed while receiving tube feeding, contrary to the requirement for head-of-bed elevation to reduce aspiration risk. Staff interviews indicated a lack of awareness and adherence to standard practices, such as checking tube placement and residuals, and there was confusion about proper documentation and communication with the physician regarding feeding issues. Additionally, the facility failed to accurately monitor the resident's weight, as weights were recorded without accounting for the weight of the wheelchair cushion, leading to inaccurate assessments of the resident's nutritional status. Family members reported concerns about the resident's weight loss, lack of nutrition, and inadequate care, which were not thoroughly investigated by facility leadership. The Medical Director and facility administration were unaware of the ongoing issues with the resident's enteral feeding and weight loss, and there was no evidence that standard practices for enteral nutrition management were being followed or that staff were properly trained in these procedures.
Failure to Prepare Pureed Chicken to Proper Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure that pureed chicken lunch entrees were prepared to the proper texture for four residents who required a pureed diet. Review of the dietary recipe for Maple Glazed Puree Chicken specified the use of a food thickener to achieve the correct consistency, but observation in the kitchen revealed that the pureed chicken contained water surrounding the chicken, indicating improper preparation. The Dietary Aide admitted to forgetting to add the thickener due to being busy, and the Dietary Manager acknowledged that the thickener gel could have been mixed in to correct the issue. The Dietary [NAME] confirmed that the thickener was not used for the puree chicken. The residents affected included individuals with significant medical needs such as quadriplegia, traumatic brain injury, cerebral palsy, malnutrition, and dysphagia, all of whom required a mechanically altered or pureed diet as documented in their medical records. The failure to follow the prescribed recipe and dietary orders resulted in the pureed chicken being served in an improper texture, which could make the meal unpalatable and difficult to swallow for these residents.
Failure to Maintain Safe Food Storage and Sanitary Water Containers
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at or below 41 degrees Fahrenheit as required by professional standards and facility policy. Observations revealed that the refrigerator temperature was not recorded for two days, and when checked, the thermometer read 46 degrees Fahrenheit in the morning and 42 degrees Fahrenheit in the evening. The Dietary Manager confirmed that temperatures were supposed to be checked and recorded daily, and that staff should have reported any temperature deviations for service. The Administrator also stated that staff were expected to monitor refrigerator temperatures daily. Additionally, the facility did not ensure that bedside water containers were cleaned and sanitized daily as per policy. Three residents were observed with water containers that had an unknown brown substance on the sides or handles, and one container was found in a bathroom on the back of a toilet tank. The Dietary Manager admitted that water pitchers were supposed to be cleaned every morning but was not fully up to date with all policies and acknowledged that the facility did not have two complete water container sets for each resident as required. The Activities Director confirmed that both nursing and dietary staff were responsible for ensuring the cleanliness of water containers.
Environmental Cleanliness and Safety Deficiencies Identified
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of unclean bathroom vents, improper storage of urinals and plungers, and unsafe or broken fixtures and equipment. Surveyors observed thick dust and cobwebs on bathroom vents in several resident rooms, with one instance of a spider hanging from a cobweb near a toilet. In multiple bathrooms, plungers were found in direct contact with the floor, and in one case, dead bugs were present in a light fixture cover. Additionally, urinals were found hanging on handrails without proper labeling or sanitary storage, and a bathroom light was missing its cover, exposing bulbs and mechanisms. Further observations revealed a broken bed footboard with sharp nails and screws exposed on top of a resident's dresser, creating a potential hazard. The Maintenance Director (MD) confirmed these issues during follow-up observations and stated that housekeeping staff were expected to clean vents and that plungers should be stored in plastic tubs to prevent contact with the floor. The MD also acknowledged that urinals should be stored in bags for sanitation and that the broken bed footboard posed a risk of accident. The MD reported that maintenance requests are typically submitted via a mailbox and paperwork slips, but no requests had been received for the observed issues. The facility's policy on routine maintenance assigns responsibility to maintenance staff for ensuring preventative and routine maintenance in compliance with life safety standards. However, a housekeeping policy was requested but not provided before the survey exit. The deficiencies were identified for 11 out of 26 residents observed for environmental conditions, with direct observations and confirmations by the MD, but without evidence of timely maintenance or housekeeping intervention prior to the survey.
Failure to Ensure Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents who were at risk for falls and had significant medical conditions. One resident, who had end stage renal disease and chronic obstructive pulmonary disease, was observed on multiple occasions with her call light clipped to the privacy curtain approximately three feet out of reach. She was unaware of the location of her call light, and her daughter reported that it was usually clipped to the curtain when she visited. This resident had a documented history of multiple falls during her stay, including unwitnessed falls resulting in a bruise to the face. Another resident, with a history of a right femur fracture and epilepsy, was also observed on several occasions with his call light draped over a wall light fixture, out of his reach and sight. This resident was moderately cognitively impaired and had a recent history of falls. Staff interviews confirmed that call lights should be within reach of residents and that all staff were responsible for ensuring this, but observations showed that this was not consistently done for these residents.
Failure to Honor Resident Bathing Preference Due to Equipment Issues
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for bathing type, specifically not providing the resident with a shower as requested. The resident, who was cognitively intact with a BIMS score of 14 and had quadriplegia (C5-C7 incomplete), depression, and hypertension, had indicated that having a bath of his choice was very important. Despite this, the resident's care plan did not address his bath or shower preferences, and records showed he consistently received bed baths on scheduled days. Multiple staff interviews confirmed awareness of the resident's preference for showers over bed baths. However, staff reported that the shower bed was broken, and the resident was unable to use the available shower chair due to lack of leg rests, which was problematic given his lack of leg control. Maintenance records indicated the shower bed was out of service for a period due to missing wheels, but there was no documentation of concerns prior to the incident. As a result, the resident's right to make choices and have preferences honored was not supported.
Failure to Timely Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an allegation of abuse involving one resident. According to the facility's policy, any incident of alleged abuse, neglect, exploitation, or mistreatment must be reported to the State Survey Agency (SSA) and the facility Administrator immediately, or within specified timeframes depending on the severity. A resident with diagnoses including COPD, vascular dementia, fibromyalgia, depression, and anxiety, who was cognitively intact, reported that a night shift CNA had verbally abused her by cursing at her. The resident stated she reported this incident to the Activity Director (AD) but could not recall the CNA's name or the exact date of the incident. The AD confirmed that the resident had reported the allegation during a Resident Council meeting but did not take further action to investigate or report the incident, instead sharing the information with the Social Services Director (SSD) for follow-up. The SSD did not learn of the allegation until several days later and only then informed the Administrator, who was unaware of the incident until that point. The Administrator stated that her expectation was for such allegations to be reported to her immediately for appropriate follow-up and notification to the SSA. The delay in reporting and investigating the allegation resulted in noncompliance with the facility's abuse reporting policy.
Failure to Obtain Level Two PASARR Assessment for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to obtain a Level Two Pre-Admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with psychiatric diagnoses, including schizoaffective disorder, anxiety disorder, and major depressive disorder. Documentation in the electronic medical record showed that the resident's Level One PASARR, completed prior to admission, did not reflect these psychiatric diagnoses. The resident was later noted to have moderate cognitive impairment and exhibited behaviors such as wandering, paranoia, exit seeking, and combativeness, which resulted in a transfer to a psychiatric hospital for evaluation. Interviews with facility staff revealed that the Social Service Director was not notified to redo the PASARR for the resident, despite suspecting that the psychiatric diagnoses were present before admission. The Administrator was unaware that the resident had been admitted with diagnoses that would have required a Level Two PASARR assessment. The lack of coordination and communication led to the failure to complete the required assessment, as identified through record review and staff interviews.
Failure to Develop Comprehensive Care Plans for Pain and ADL Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy. One resident, who had diagnoses including arthritis, pain in the left hip and right hand, muscle weakness, and general pain, was receiving both morphine and acetaminophen for pain management. Despite an increase in pain reported by the resident and the presence of physician orders for pain medications, there was no care plan in place addressing pain management, non-pharmacological interventions, or the use of pain medications. The MDS Coordinator confirmed that a pain care plan should have been developed but was omitted. Another resident, admitted with diagnoses such as congestive heart failure, anxiety, glaucoma, and adult failure to thrive, was found to have severely impaired cognition and was dependent on staff for all activities of daily living (ADLs), including oral hygiene, toileting, showering, dressing, personal hygiene, eating, bed mobility, transfers, and mobility. However, there was no care plan addressing the resident's need for assistance with ADLs. The MDS Coordinator acknowledged that the resident's total dependence on staff for ADLs should have been included in the care plan.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on nursing staff for all aspects of care and had moderate cognitive impairment, was observed to have fingernails extending more than half an inch beyond the fingertips. The resident, who had a history of a right femur fracture, chronic obstructive pulmonary disease, and epilepsy, was admitted to the facility and had a care plan stating the resident would be kept well-groomed. Despite this, observations on two consecutive days confirmed that the resident's nails remained untrimmed, and the resident expressed a preference for having them trimmed. Interviews with staff revealed confusion regarding responsibility for nail care, particularly for residents on hospice. One LPN initially stated that the hospice aide should have trimmed the nails, but acknowledged that facility staff were responsible if hospice did not perform the task. CNAs and another LPN confirmed that facility staff were responsible for nail care unless the resident was diabetic, in which case a nurse would perform the task. The failure to provide nail care resulted in the resident having unmet care needs.
Failure to Notify Resident of Scheduled Physician Appointment
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, depression, and hypertension was not properly notified of a scheduled physician's appointment. The resident, who was cognitively intact, was informed of the appointment at the last minute, leaving insufficient time to prepare. The resident subsequently refused to attend the appointment due to not being ready. The appointment had been rescheduled weeks prior, and the information was documented in both the master notebook at the reception desk and the appointment book at the nurses' station. Interviews revealed that the process for notifying residents of appointments was unclear, with no specific staff member assigned to this responsibility. The assigned RN was unaware of the appointment due to a contract nurse working the previous night and not being familiar with the appointment notification process. The lack of a clear notification protocol led to the resident missing the scheduled medical appointment.
Failure to Provide Ordered As-Needed Medication and Notify Physician After Missed Dialysis Appointment
Penalty
Summary
A resident with end-stage renal disease (ESRD) who required regular dialysis missed a scheduled dialysis appointment due to transportation issues. The facility's policy for care of residents with ESRD did not address procedures for missed dialysis appointments. The resident had a physician's order for Lokelma, to be administered as needed on missed dialysis days, but this medication was not given when the appointment was missed. There was also no documentation in the electronic medical record (EMR) regarding the missed appointment, and the physician was not notified of the incident. Interviews with facility staff revealed that the LPN responsible for the resident on the day of the missed appointment was unaware of the as-needed order for Lokelma and did not check for such orders, as they were not scheduled medications. The Director of Nursing stated that she was not aware of the missed appointment and would have expected documentation, physician notification, and administration of Lokelma as ordered. The resident's care plan included instructions to inform a family member if transportation had not arrived by the scheduled time, but there was no evidence this was done.
Failure to Arrange Dental Visit Following Physician Order
Penalty
Summary
The facility failed to ensure that a resident received a dental visit as ordered by the physician to address a mouth infection. The resident, who had diagnoses including ulcerative oral mucositis and cirrhosis, was observed to have several missing teeth and a broken tooth, and reported pain and difficulty eating. The physician had prescribed antibiotics and ordered a dental appointment as soon as possible due to a tooth and gum infection. However, there was no documentation of a dental visit in the resident's medical record or hard chart. Interviews with facility staff revealed a breakdown in communication regarding the dental appointment order. The Social Services Director was unaware of the physician's order, and the receptionist had not received any request to schedule a dental appointment. The DON confirmed that the nurse responsible for reviewing the physician's order did not communicate the need for a dental appointment to the appropriate staff for follow-up, resulting in the resident not being seen by a dentist.
Failure to Maintain Accurate Physician Orders in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date physician orders for three residents, resulting in discrepancies in the provision of hospice, dialysis, and restorative services. For one resident with chronic obstructive pulmonary disease and moderate cognitive impairment, hospice orders remained active in the electronic medical record (EMR) even after services were discontinued, as confirmed by the administrator. Another resident with end-stage renal disease and other comorbidities continued to have an active physician order for dialysis at a clinic that had closed, despite receiving dialysis at a different center for several months. The administrator acknowledged the inaccuracy and the need to update the EMR. A third resident, who had a history of cerebral infarction and required substantial assistance for self-care, had outdated orders in the EMR for restorative therapy and splint use, even though the resident no longer used splints and the facility no longer had a restorative therapy program. The administrator confirmed that the range of motion exercises were not being performed as ordered and that the order should have been discontinued. These findings were based on interviews, record reviews, and policy review, and were corroborated by staff and external providers.
Failure to Ensure Staff Use of PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) as required under Enhanced Barrier Precautions (EBP) for three of five residents reviewed. According to the facility's policy, EBP requires staff to wear gowns and gloves during high-contact care activities for residents with certain conditions, such as open wounds or indwelling medical devices. Observations revealed that staff did not consistently follow these requirements during care activities for residents with pressure ulcers and other qualifying conditions. For one resident with stage three pressure ulcers, a wound physician and a wound LPN entered the resident's room, which had EBP signage, and performed wound care using only gloves and not gowns. Both staff members confirmed in interviews that they did not wear gowns, with the physician stating that gowns were not available at the time. The infection preventionist later confirmed that these staff members had not received EBP training and that gowns should have been worn during such care. In another instance, a CNA from an agency provided incontinence care and changed bed linens for a resident with a pressure ulcer, wearing only gloves and not a gown. The CNA stated it was her first day at the facility and that gowns were not available in the room. The infection preventionist confirmed that the resident required EBP and that the CNA should have worn a gown. Additionally, another CNA was observed attempting to dress a resident with EBP signage on the door without donning any PPE. These failures were observed despite the facility's policy and posted signage indicating the need for EBP.
Failure to Administer Consented Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that two of five residents reviewed for vaccinations, who had provided consent, were administered the appropriate flu or pneumonia vaccines. One resident, admitted with dementia and a right lower leg fracture, had signed a consent form to receive the pneumococcal vaccine, but there was no documentation in the electronic medical record (EMR) that the vaccine was administered. The Infection Preventionist confirmed during an interview that the resident had consented and the vaccine should have been given, but it was missed. Similarly, another resident admitted with a left heel pressure ulcer had consented to receive the influenza vaccine, as documented in the consent form. However, the EMR contained no record of the vaccine being administered. The Infection Preventionist acknowledged that the resident had been missed and that the vaccine should have been given in a timely manner after consent was obtained. These findings were based on record review, interviews, and policy review.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its pressure ulcer and wound care policies, resulting in deficiencies in the care of two residents with pressure ulcers. For one resident, the facility did not initiate the wound care physician's orders or follow the registered dietician's recommendations promptly. The resident had a pressure ulcer on the coccyx, which was not properly documented or treated according to the physician's orders. Additionally, the resident developed pressure ulcers on both feet/heels, which were not identified, assessed, or reported to the physician in a timely manner. The facility's failure to update the resident's care plan to reflect the presence of pressure ulcers further contributed to the deficiency. Another resident was admitted with a pressure ulcer on the coccyx, but the facility did not have a treatment order in place until several days after admission. The resident's pressure ulcer was not treated according to the wound care physician's orders, and the registered dietician's recommendations for nutritional supplements were not implemented promptly. The facility's lack of communication and documentation regarding the resident's treatment orders and care plan updates led to inadequate care for the resident's pressure ulcer. The facility's wound management program policy outlines procedures for assessing and treating pressure ulcers, but these procedures were not followed. The facility failed to ensure that new treatment orders from the wound care physician were implemented promptly and that registered dietician recommendations were acted upon within a reasonable timeframe. The lack of communication and documentation among staff members, including CNAs, LPNs, and RNs, contributed to the deficiencies in pressure ulcer care for the residents.
Failure to Monitor COVID-19 Positive Resident
Penalty
Summary
The facility failed to monitor a resident diagnosed with COVID-19 in accordance with their policy. The resident, who had moderate cognitive impairment and was dependent on activities of daily living, tested positive for COVID-19. Despite the facility's policy requiring increased clinical monitoring, including assessments of symptoms, vital signs, oxygen saturation levels, and respiratory exams every shift, there was no documentation of these assessments in the resident's medical record. The resident's care plan also lacked documentation of the COVID-19 diagnosis. Interviews with staff revealed that the resident exhibited changes in condition, such as being more down and depressed, and not eating breakfast, which were reported to the registered nurse. However, the registered nurse did not document the vital signs in the resident's medical record. Subsequent shifts also failed to document vital signs or monitor the resident's condition as required. The resident was found unresponsive during perineal care, and CPR was initiated but was unsuccessful. The cause of death was determined to be COVID-19. The Director of Nursing confirmed that the facility's COVID-19 and Change in Condition policies were not followed. The expectation was for the charge nurse to obtain and document vital signs each shift to monitor the resident's condition and notify the physician of any changes. The failure to adhere to these policies resulted in a lack of proper monitoring and documentation for the resident diagnosed with COVID-19.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
